Neurological symptoms in a traveller returning from Central America

Abstract. Keynan Y, Pottesman I (Bnei Zion MedicalCenter, Haifa, Israel). Neurological symptoms in atraveller returning from Central America (Casereport). J Intern Med 2004; 256: 174–175.Keywords: ciguatera, ciguatoxin, dysesthesia, fishpoisoning, paresthesia.Ciguatera fish poisoning is a clinical syndromecaused by the ingestion of fish containing cigua-toxin. It is considered the most common food-borneillness related to fish consumption [1]. The disease isendemic in tropical and subtropical regions of thePacific and Indian oceans and Caribbean, althoughsporadic outbreaks have been known to occur intemperate areas. Ciguatoxin is manufactured by thedinoflagellate Gambierdiscus toxicus, and becomesconcentrated upwards throughout the food chain[1]. Fish commonly implicated in transmission of thetoxin include mackerel, barracuda, red snapper,amberjack, sea bass and grouper. The toxin is stablein gastric juice and is not inactivated by freezing orcooking. It induces prolonged opening of voltage-gated sodium channels in nerves and muscles [2, 3].The manifestations of poisoning fall into four categ-ories: gastrointestinal, neuropathic, cardiovascularand a diffuse pain syndrome [1].The neurological manifestations include periph-eral sensory or motor symptoms, severe headacheand autonomic dysfunction, which in severe casesmight lead to bradycardia and hypotension. Pares-thesia and dysesthesia are very common, and‘reversal of thermal sensation’ (cold stimuli beingfelt as painful or burning) is considered a pathog-nomonic symptom. Other signs include pruritus, ametallic taste in the mouth, insomnia and cere-bellar signs. The symptoms can recur intermit-tently over a period of several months, sometimesaccompanied by fatigue, weakness and hypersom-nolence [2].Management is primarily supportive, because noantitoxin is available. Amitriptyline has been usedfor relief of the neurological symptoms [3]. Mannitolproduced immediate resolution of symptoms in anuncontrolled trial, an effect that was not seen in alater randomized trial [1]. Gabapentin was usedsuccessfully to treat two patients with neuropathicpain [4].We report the case of a female patient presentingwith neurological symptoms after a trip to CentralAmerica.